LPN Care Coordinator

Robert C. Byrd Clinic•Lewisburg, WV

6d•Onsite

About The Position

WVSOM Health is seeking a full-time LPN Care Coordinator to support physicians, mid-level providers, and nurses in delivering care in a clinic environment. The position assists patients who contact the clinic and serves as part of an interdisciplinary care team, providing timely care in person and through telephone and EHR portal communications. The role also assists with Chronic Care Management (CCM), Transitional Care Management (TCM), and Remote Patient Monitoring (RPM). The position requires graduation from an accredited practical nursing program, West Virginia practical nurse licensure, current BLS certification, and at least three years of clinical-setting experience. Strong communication and customer service skills, knowledge of disease processes and healthcare protocols, and strong computer skills are required. Familiarity with EHR platforms is preferred. Knowledge of CMS guidelines and documentation requirements for CCM, TCM, and RPM, as well as experience in care coordination, chronic disease management, population health, or value-based care, are preferred. WVSOM Health is a not-for-profit Rural Health Clinic in Lewisburg, West Virginia, and a primary clinical training site for WVSOM students, interns, and residents. Employment is contingent upon completion of a post-offer drug screen, I-9 form, and background investigation. WVSOM Health is an Equal Opportunity Employer.

Requirements

Graduate of an accredited School of Practical Nursing (LPN) program.
At least three years of experience in a clinical setting.
West Virginia licensure as a Practical Nurse.
Current BLS certification.
Strong communication and customer service skills.
Thorough knowledge of disease processes to support appropriate patient triage and care.
Comprehensive understanding of healthcare practices and protocols.
Excellent computer skills.

Nice To Haves

Experience using electronic health record (EHR) platforms.
Knowledge of CMS guidelines and documentation requirements for CCM, TCM, and RPM.
Experience with care coordination, chronic disease management, population health, or value-based care.

Responsibilities

Provide direct patient care as assigned and qualified, under the direction of a nurse, physician orders, or established protocols.
Answer patient calls courteously, respond to healthcare inquiries, and use de-escalation techniques with upset patients.
Document phone interactions, including attempted calls, in patient charts.
Conduct phone interviews to gather information for providers.
Schedule appointments promptly and return calls by the end of the day.
Welcome patients, address concerns, and help ease anxiety.
Triage patients according to urgency and clinic protocols.
Record vital signs and update patient histories.
Conduct initial patient assessments and participate in patient education.
Maintain accurate patient records and complete charting promptly.
Process stat referrals efficiently.
Assist CCM patients with monthly outreach, care plan development and updates, medication reconciliation, goal setting, and required documentation.
Assist with TCM activities, including post-discharge outreach, medication reconciliation, follow-up appointment coordination, patient education, and communication with providers and community resources.
Assist with RPM by reviewing transmitted physiologic data, identifying abnormal findings, notifying providers of significant changes, educating patients, and documenting interventions.
Coordinate care among primary care providers, specialists, hospitals, home health agencies, pharmacies, and community resources to promote continuity and reduce hospital readmissions.
Maintain timely and accurate documentation for CCM, TCM, and RPM in accordance with CMS, payer, and organizational requirements.
Participate in quality assurance and patient care meetings.
Perform other duties as assigned.
Adhere to WVSOM Health's customer service standards.